RSSAuthor Archive for Steve MacArthur

Steve MacArthur

Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

How long has this been going on?

We’re rounding the turn and headed for home – no squeeze play at the plate this time…I hope!

EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems (#16, with 24% of hospitals having been cited)

It seems to me that we’ve discussed this in the past as well, but it appears that, in this survey year, everything bears repeating.

Anything that your medical gas and vacuum testing activities generate as deficiencies/recommendations/hints from Heloise/etc. needs to be accounted for somehow. Maybe your medical air intake is right next to an isolation exhaust, or it’s nothing more than a leaky outlet, or the issue is non-compliant construction (a favorite is the medical gas zone shutoff valve in the PACU with no intervening wall) that can wait until you do a remodel/renovation project. Whatever it is, you need to say, “This is what we’re doing about that, based on our assessment of the involved risks.” And don’t wait to get ahead of the curve on the fixes: As soon as the activity is completed you are on the hook for the fixes, so you need to know what’s on that list even before you get the pretty report. The clock starts ticking upon identification of the condition, so if you have to wait a month or 45 days for the report, you (and more importantly, your patients) are at some level of risk.

The other thing to do is make sure that your vendor is not using this process to drum up work; I can’t tell you how many times I look at multiple years of testing documentation and find the same “deficiency” over and over again – and then find out, well, it’s not really a deficiency at all. You will get slapped during a survey for this – if it’s a critical fix, then fix it, if it’s not a critical fix, then dot the “I’s” and cross the “t’s” and make sure they are accounted for.

Another component of this is obstructed access to zone shutoff valves, as well as making sure that the labeling of valves is accurate (areas served, contents of piping – labels have to be accurate, accurate, accurate). Also, make sure that what you are calling the area of coverage is in some sort of accordance with what the staff calls the area. I can’t tell you how many times that I’ve seen zone valves labeled in accordance with the architectural drawings and find out that front line staff really doesn’t know which areas are served by the valves. Knowledge is very powerful, and certain knowledge is an invaluable commodity during surveys.

EC.02.05.07 – Inspection, testing and maintenance of emergency power systems (#17, with 23% of hospitals having been cited)

Emergency generators and automatic transfer switches have to be tested in accordance with the requirements of EC.02.05.07 – if you need me to tell you what those are at this point, you may be in the wrong line of work. However, I am more than happy to answer any questions you might have regarding this most important subject. 30%, 30 minutes, no closer than 20, no greater than 40 between tests, run it for 4 hours at a minimum 30% load every 36 months – these are a few of my favorite things.

EC.02.03.01 – Management of fire risks (#20, with 19% of hospitals having been cited)

Breathing a sigh of relief, we’re near the end of our little journey through time and (interstitial) space.

This is another of those findings that it becomes a question of how far one must look before one can encounter enough deficiencies to drive an RFI (the answer in this case being 2). The question I have for you is this – how many junction boxes do you have in your facility. 100? 1,000? 10,000? So, the follow-up question is: How many would an individual (say, a Joint Commission Life Safety surveyor) have to look at before they found two that didn’t have a cover? There are so many opportunities to drop the ball on this one – mechanical spaces, comms closets (it’s very rare that I find an open j-box in an electrical closet – but not impossible). You know they’re going to look above the ceiling – and they’re not just looking for penetrations – and cabling on sprinkler piping – and, and…

You need to enlist the efforts of everyone who does work above the ceiling in your facility; they don’t necessarily have to fix it, but if you know where it is, then you have a shot at being able to address it before it gets ID’d during a survey. The proactive approach works unbelievably well for stuff like this.

And on the horizon looms the specter of a return to focus for the prevention of surgical fires – including the participation of physicians. Too many (and my stance is that one surgical fire is too many) surgical fires occur for my (or anyone’s) liking, so it’s time to kick this process into high gear. I know they’re busy, and may not always seem to be the most cooperative bunch on the planet, but this I see as a moral imperative (and it appears that TJC is similarly inclined – so if you won’t do it for me, do it for them). We can do a better job of educating folks about the risks of surgical fires – and so, we must do just that.

One other related thought is to make sure that you are appropriately managing amounts of compressed gas – don’t go over 12 e-cylinders in an unprotected area. And make sure that your gas storage rooms (for amounts greater than 300 cubic feet of gas) are appropriately fire-safe, etc.

This concludes our test of the emergency survey broadcasting system – this was only a test. We now return you to our regular programming, which is already in progress. If you have any questions or concerns about this or any other topic, you know where I am…

And where it’s going, no one knows

Continuing on our recap of survey adventures, we finish out the Top 10:
EC.02.06.01 – Establishment and maintenance of a safe, functional environment (#9, with 32% of hospitals having been cited)
A couple of somewhat disparate conditions are coalescing under this particular standard:

  • Safety and suitability of interior spaces – this apparently is where the unsecured compressed gas cylinders are ending up when they are found during survey. Not necessarily the place I would have picked (I’d run with EC.02.01.01 EP #3 – minimization of safety risk in the environment), but I can see where it would fit;
  • Management of ventilation, temperature and humidity in the care environment – this is one that will cause you so much heartache, it’s not funny. Temperature and humidity logs? You better have ‘em (and yes, I know that they are not specifically required in the regulatory verbiage, but that doesn’t mean a (insert descriptor of your choice) thing. Trust me on this, if on nothing else, ever!) Make sure that you have extremely reliable pressure relationships in every spot where you’ve got clean/soiled environments cheek-to-jowl; clean/sterile; sterile/soiled, etc. The air has got to flow from the good to the bad (euphemistically speaking), if it flows from the bad to the good, you are going to get lit up like a Roman candle during survey, likely resulting in a CMS visit to boot – none of us want that, none of us at all.
  • Finally, and I don’t know that this got a whole lot of play in the official version, but there is a universal opportunity relative to cleanliness in the patient environment. There are some that I’ve seen who do a pretty good job, but I also know that I’ve not encountered anything close to perfect. If you have a surveyor with a mind to find dust, etc. somewhere in the patient environment, it will be found and it will be cited. Tell me the EVS folks aren’t shoveling against the tide sometimes…

EC.02.02.01 – Management of Hazardous Materials Risks (#10, with 29% of hospitals having been cited)
Lots of funky conditions can reside here, to name just a couple:

  • Management of eyewash stations – weekly checks, temperature, obstructions, where they are installed, etc.
  • Labeling secondary containers – if the chemical leaves its home vessel and is placed in another vessel, the second vessel (spray bottle, basin, sink) needs to have the hazard identified, unless the second vessel is absolutely attended until it is used/properly disposed – and even then, I’d do the label;
  • Access to the Hot Lab in Nuclear Medicine – you’ve got to have a policy that makes sense about access, particularly for couriers delivering the materials – and remember, they’re already driving around with the stuff – if they want to swipe the stuff, they’ll just keep driving – so keep an eye on your stuff (George Carlin would want you to). That said, you should track down the July 2012 edition of Perspectives – there’s a lovely article on just this subject – can you say risk assessment? Thought so.

OK, we’ll do one more for this week, breaking into the next 10
EC.02.05.01 – Managing risks associated with Utility Systems (#11, with 28% of hospitals having been cited)

For those of you with older buildings and/or older utility system components, this one may keep you up at night. The sort of overarching way this is popping up during surveys (other than temperature, humidity, and ventilation, about which we’ve already spoken and will, no doubt, speak of again) is the inability of the system (whichever system it might happen to be) to achieve required results. Now, the sticking point here relates very much to what constitutes a “required result”. In case you hadn’t noticed, CMS is pretty much calling the shots when it comes to enforcement and, with increasing frequency, the practice of grandfathering older, lesser-performing systems is going by the wayside. If you (or someone you love) has a utility system that is not performing up to modern standards, then you had best get going on a risk assessment and identify mitigation strategies for appropriately managing the risks associated with the current performance level of the systems (and, perhaps, a plan for how you’re going to get to where you need to be).

The other condition that has been popping up is the identification, in writing, of inspection and maintenance activities (and the appropriate intervals) for all operating components of utility systems on the utility management inventory (which is, of course, populated through an arduous risk assessment process). It’s my understanding that continuous monitoring through the good graces of a building automation system is an acceptable means of compliance with this requirement, but if you don’t have a building automation system, you’d best be prepared to produce, in writing, the activities and intervals as noted above (a computerized work order system might work – but it has to be a pretty robust platform).

And so we’ve reached the end of yet another batch of fun facts and figures – next week, we’ll wrap it all up – until next year!

Wait there’s more – three men in black said don’t report this…

So, we’ll start this week’s coverage with that pesky little Infection Control (IC) finding (yes, I do recall saying that I would make sense of this as a function of the EC/LS continuum):

Managing the risks of infections associated with medical equipment, devices, and supplies (#5 on the list of top-cited standards, with 39% of hospitals having been cited – IC.02.02.01)

This primarily has  to do with the various and sundry methods of disinfection that are used in the healthcare environment, from low-level disinfection (EP 1), which includes the presence of expired product (i.e., spray disinfectant, disinfectant wipes) to ensuring that staff are knowledgeable of how long they have to keep the surface wet in order to disinfect said surface. And that’s not just the folks in EVS, that’s everybody who wipes something down with a disinfectant. If the goal is to disinfect the surface (which is different than cleaning – cleaning doesn’t take as long), then everyone who uses the stuff has to know how long the surface has to stay wet.

The next component is the intermediate- and high-level disinfection and sterilization processes, particularly when it comes to the manual disinfection of medical equipment. We’ll be chatting about this more in the future, but (and I will eventually reiterate – but don’t I always?), if there are folks in your organization who are performing manual disinfection of patient care devices/instruments, most frequently using an OPA product – you need to make sure that the process has been evaluated  as a function of what is actually required by the manufacturer.  This is a very complicated process (with lots of steps to go awry), and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…did I say perfect? Indeed, I did!

You also have to make sure that you are properly disposing of medical equipment, devices, and supplies – which means it is vewwy vewwy important that everyone understands what constitutes medical waste – how bloody, etc. do things have to be before they go into the red bag.

Finally, this one deals with the storage of medical equipment, devices, and supplies. This could be any number of things, one of which is not particularly negotiable – outdated stuff – no real defense there. But it could also be any one of those bugaboos – storage under the sink, uncovered linen carts, cardboard, non-solid bottom shelves of storage carts, etc. If I’ve said this once, I’ve said it a million times – there are no (nationally promulgated – check your local listings for regulations near you) rules about these. Each of these is a case of self-determination on the basis of a risk assessment – each represents an infection control risk. Our obligation is to identify the most effective means of managing those risks.

So, as you can see, this is all stuff that fits ever so neatly into the EC world – always more to keep an eye on, don’t you know.

LS.02.01.30 – Provision and maintenance of building features to protect individuals from fire and smoke (#7 on the top-cited list, with 36% of hospitals having been cited)

As the list of non-surprise issues continues, we find ourselves facing non-intact smoke barriers (Can you say “penetrations” again? Good!) and door issues. Hopefully, you all are starting to become familiar with the specifics (you’d better be); EP16 – 23 are providing the most compelling fodder for survey findings. Also, findings relative to the protection of hazardous areas – once again, door latching issues, doors that don’t self- or auto-close and latch (maybe because they’ve been wedged open or had a latch taped over), maybe the odd penetration – pretty basic stuff, all in all.

LS.02.01.35 – Fire extinguishing system requirements (#8 on the list, with 35% of hospitals having been cited)

Eighteen-inch storage leads the parade, but other things to keep an eye out for are:

  • Cabling and other materials draped over/attached to sprinkler piping (including the supports) – chances are you’ve got some of this somewhere in your building – it’s up to you to find it before TJC does.
  • Dust and/or other materials (including grease) on sprinkler heads – gunked-up sprinkler heads don’t work nearly as effectively as those that are pristine. By now, you (or your sprinkler contractor) should have a pretty good idea of which heads are susceptible to build-up of ca-ca.
  • Missing escutcheons – if we only knew where the blessed things went. It’s like some sort of black hole or extraterrestrial event – they disappear and we’re on the hook.

And look, we haven’t even quite finished with the top 10 yet , but rest assured…

Where’s the devil? In the details, of course.

So now that we know the numbers, let’s dig in to what continues to make these little darlings such the rage when it comes to the current survey process:

LS.02.01.20 – Integrity of means of egress (#2, with 52% of hospitals having been cited)

Corridor clutter – I don’t care what’s going to happen with the adoption of the 2012 edition of the LSC (whenever it happens – 2014, anyone?), this one is not going away and, let’s admit it, this one is almost impossible to avoid, especially when you bring in the questionable designation of suites (or non-designation as the case may be; we’ll talk more about suites in the coming weeks, but suffice for now,you need to familiarize yourself with EP’s 16 – 22 on this one, and make sure the suites are identified on your life safety drawings).

Another issue that I continue to encounter is the issue of locked egress doors, especially in areas other than behavioral health units (but, please make sure on the behavioral health units that every staff member has a key). You need to become intimately familiar with the requirements under NFPA 101-2000: 18/ and all associated references (it jumps back to Chapter 7 – and best you make the jump as well).  Security hardware vendors will install equipment in a manner that will get you into hot water during a survey if you don’t pay attention. As a final note, I suspect that exit signs and NO exit signs figure in on this one as well. As always, lots of opportunities for deficiencies here, that’s kind of why it sits so very close to the top of the list…

LS.02.01.10 – Design and maintenance of building and fire protection features (#3, with 47% of hospitals having been cited)

Can you say penetrations? I thought you could! Again, no surprises here – penetrations in fire rated walls. Other non-surprises, you might ask? Door issues – closing, latching, unapproved protective plates, gaps between meeting edges of door pairs, undercuts, decorations and coverings on rated doors – again, how far would they have to look to find these in your “house?” Also, apparently, issues with dampers missing from fire walls – you gotta know where your fire walls are and you gotta know where the dampers (or “dampahs,” as we say in Boston) are. You can get into more trouble by not knowing stuff…

EC.02.03.05 – Maintenance and testing of fire safety equipment and fire safety building features (#4, with 40% of hospitals having been cited)

Again (and I’m going to stay on this one until it finally goes away), my most fervent wish is to make this one history. There are 25 Elements of Performance, representing hundreds if not thousands of opportunities for someone to screw up. Miss a couple of smoke detectors because they were in occupied patient rooms and boom: RFI! Not running the weekly fire pump test for at least 10 minutes, boom: RFI! Miss a couple of fire extinguishers one month (or a single extinguisher for a couple of months), boom: RFI! One of your vendors not indicating the NFPA standard on their documentation, boom: RFI! Do I need to continue? I think not. BTW – this is the #1 most frequently cited standards for critical access hospitals.

And an additional BTW – if, by some strange quirk of fate, you don’t have the documentation available for the surveyor at the time of survey, you don’t just get dinged under EC.02.03.05, but also under the Leadership standards (LD.04.01.05, EP #4 for those of you keeping track). You absolutely, positively have to have the documentation readily available at all times! Even if you go the post-survey clarification route and succeed in establishing a score of compliant for EC.02.03.05, the leadership RFI will stay – because you should have had the documentation available!

I think that’s enough for this week, but stay tuned for the next installment of “Survivor: TJC.”

And the beat goes on – La de da de de, la de da de da…

Alright – so anybody come up with any bright ideas about the looming presence of the EC/LS standard in the list of most frequently cited standards during Joint Commission surveys? Keep those cards and letters coming and maybe we’ll make some sense of this whole thing.

One good thing I can report (and we’ll cover the numbers more thoroughly when we discuss the individual standards and potential vulnerabilities) is that there was some improvement in the standards cited towards the top of the charts, but there were definitely some rising tides as well. Continuing through the rest of the 20, we have:

–          At #11, with 28% of hospitals having been cited – EC.02.05.01 – Managing risks associated with Utility Systems

–          At #16, with 24% of hospitals having been cited – EC.02.05.09 – Inspection, testing and maintenance of medical gas and vacuum systems

–          At #17, with 23% of hospitals having been cited – EC.02.05.07 – Inspection, testing and maintenance of emergency power systems

–          And, at #20, with 19% of hospitals having been cited – EC.02.03.01 – Management of fire risks

So, only 40% representation in the 11-20 group, but for my money, this is getting kind of ridiculous when you think about it.

All in all, I think we (in the aggregate) do a pretty decent job of protecting folks in our organizations from the various and sundry risks that we might encounter.  (I believe to my heart that we haven’t quite hit our stride relative to the management of risks associated with workplace violence, but we’re getting there, but that’s the only area in which I generally see significant improvement opportunities.) We do not generally have people perishing from fires in hospitals, and while we may not get everything right every single time (we demand perfection, but the human element frequently intrudes on that demand), I believe that hospital safety/life safety/facilities professionals perform at a very high rate (keep that thought about rates in your mind’s eye – we’ll come back to rate-based management of survey vulnerabilities as we move through the details of the Top 20).

I guess we avoided having to take it on the chin for a whole bunch of years, and now it’s our turn in the barrel. That said, I’m looking for lots of improvement in the next survey year – and I hope I can help you get there.  So, next week, we’ll cover each in greater detail, maybe talk a little strategy – it’s all good. Until then…

We’re number 2! We’re number 2!

As September draws to a close, it’s time for a recap of the survey year according to the information provided at Joint Commission Executive Briefings, held in locations all across this great nation.

One interesting change is that rather than covering the 10 most frequently cited standards during Joint Commission surveys, the scope has expanded to the 20 most frequently cited standards. And the reason for the expansion, you might well ask? As near as I can tell (or so I’ve been told), it’s because the Life Safety and Environment of Care standards have taken over the top 10 to the extent that the Joint needed to adjust to keep some of the clinical issues on the map.

So, by my calculations, 12 of the 20 most frequently cited standards reside pretty squarely in the management of risk in the physical environment (there’s one that may not seem to “fit”, but trust me on this – it’s definitely something we need to have on the radar. More on that in a moment).

Removing the clinical standards, we come up with a tally of:

#2, with 52% of hospitals having been cited – LS.02.01.20 – Integrity of means of egress

#3, with 47% of hospitals having been cited – LS.02.01.10 – Design and maintenance of building and fire protection features

#4, with 40% of hospitals having been cited – EC.02.03.05 – Maintenance and testing of fire safety equipment and fire safety building features

#5, with 39% of hospitals having been cited – IC.02.02.01 – Managing the risks of infections associated with medical equipment, devices, and supplies (this is the sort of an odd one, but you’ll see it fits – I gar-on-tee that)

#7, with 36% of hospitals having been cited – LS.02.01.30 – Provision and maintenance of building features to protect individuals from fire and smoke

#8, with 35% of hospitals having been cited – LS.02.01.35 – Fire extinguishing system requirements

#9, with 32% of hospitals having been cited – EC.02.06.01 – Establishment and maintenance of a safe, functional environment

#10, with 29% of hospitals having been cited – EC.02.02.01 – Management of hazardous materials risks

So, that’s an 80% showing for the EC/LS clan in the top 10. Now, one thing we’re going to have to try and figure out is this:

Are they finding this stuff because they’re looking for it? Or,

Are they looking for this stuff because it’s easy to find?

That’s your discussion point for the week – let’s see what you can come up with and we’ll get to the rest of the Top 20 next week.

(Fire) Pump it up!

Just a thought relative to a finding from a recent survey – a quick show of hands, if you will. For those of you blessed (cursed?) with having a fire pump (or two, or three, or…), when your folks conduct the weekly churn test, are they documenting the pressures at the pump as required by NFPA 25-1998, 5-

It seems that there are some instances in which the run time for the test is all that is being documented, so if you think you might be among those who aren’t documenting the pump pressures, consider yourself informed. For those of you who don’t have fire pumps, well, one less thing to worry about, which leaves about 999,999 things to worry about. You take one down, pass it around…

It only takes a minute (OK, maybe a minute and a half…)

As we continue to peel back the layers of the (green) onion that is fire alarm and suppression system testing documentation, I bring you this from the survey front: I can’t say that I find this consistently documented, which makes me think this is worth sharing with the group. By the way, for those of you who have not yet bitten the bullet, it may be time to extend your NFPA library beyond the Life Safety Code®. There are way too many pieces of the puzzle that live in the “other” codes for us to refrain for much longer (not that I am in any way endorsing any particular organization or product, but sometimes the way forward becomes impossibly clear…).

And so, turning to the testing of the emergency services notification transmission equipment (the equipment that comes into play when one must summon assistance from local/regional emergency responders), for this particular sequence of events, there is a requirement under NFPA 72, 1999 edition, 7-2.2 that indicates the receipt of the signal at the supervising station within 90 seconds shall be verified.

Now, for those of you who utilize a central monitoring service (and who, hopefully, are documenting each leg of that signal process – fire alarm system to central monitoring service; central monitoring service to the emergency responders) and, I suppose, those of you who ring directly through to the emergency responders – are you counting those precious seconds when you do your quarterly testing? If not, you would have to consider yourself a little bit vulnerable. Word to the wise.

Smoke ‘em if you got ‘em, but be careful where you install them…

Every once in a while, someone will “challenge” me relative to something I “know” is the real deal. Now, just so we’re clear on this, I absolutely encourage the respectful pursuit of knowledge, and it helps keep me on my toes, metaphorically speaking.

The issue in question during this recent survey was regarding the requirements for the placement of smoke detectors vis-à-vis the location. Or, in the vernacular, “Where does it say that it the code?” At this particular facility (as will happen from time to time), I noted that there were several smoke detectors that were located within three feet of air supply/return vents. I fully recognize that moving such devices around can represent a not-insignificant expense, so I was happy to respond to the “nobody’s ever said anything about that before” conversation, but had to admit that I was not certain as to the chapter and verse that governed this particular metric.

So, for the purposes of furthering the knowledge base, I give you NFPA 99 – 1999 edition, which is the edition of record referenced in the 2000 Life Safety Code®:

2-3.5.1*: In spaces served by air-handling systems, detectors shall not be located where airflow prevents operation of the detectors.

Now you may have noticed that there is no specific distance indicated, just a (not particularly useful) thou shalt not. So, how do we figure out where to go with this? Luckily, the little asterisk, points in a very useful direction. And so, to the Appendix!

A-2-3.5.1: Detectors should not be located in a direct airflow nor closer than 3 ft (1 m) from an air supply diffuser or return air opening. Supply or return sources larger than those commonly found in residential and small commercial establishments can require greater clearance to smoke detectors. Similarly, smoke detectors should be located farther away from high velocity air supplies.

Which provides us with a minimum distance of 3 feet (or 36 inches, for those of you inclined to such measures). While there is still a little wiggle room (not necessarily related to the little asterisk) relative to distance from larger and/or high velocity sources (in fact, you could make the interpretive case that supply and/or return sources in hospitals might indeed be larger than those commonly found in residential and small commercial establishments), this gives us the means of drawing a line in the sand beyond which we shouldn’t traverse. As a final thought, for those of you eagerly awaiting the opportunity to embrace the 2012 edition of The Life Safety Code®, the 2010 edition of NFPA 99 provides this little piece of the regulatory pie under

What I did on my summer vacation…

While I was on vacation a few weeks back, I used some of my “leisure” time to read the daily paper, and I came upon an article regarding the sentencing of a woman who had abducted an infant back in 1987 and raised the infant as her own child. One of the things that struck me is how the abduction scenario (or as much as can be discerned from the news account) involved an infant that had been discharged following delivery and had then been readmitted to the hospital a couple of weeks later. I reflected on how “useful” this scenario could be in developing abduction exercises, and I wondered how often folks are testing response in areas other than the mother-baby unit.

So, I ask you dear readers – what “other” areas have you identified as being at risk for potential abductions – inpatient, outpatient, how about in the home when mother and baby have been discharged. How are we educating staff and patients to the very real risks that exist in way too many places (in my humble opinion)? What do you think? How “far” do you take your responsibilities in this regard?